Analysis Refit not Reported to Authorities There are over 20 000 fishing vessels registered in Canada, including over 15000 with a gross tonnage of under 15(seeAppendixB). At least 76percent of Canada's fleet of registered fishing vessels are operated according to the minimum regulatory requirements of the inspection and certification system. Without any real support, the owners and masters of these vessels equip and operate their boats as they wish. It is interesting to note that, among this latter group of small fishing vessels, including the EvanRichard, the owners are not required to have their vessels inspected. However, if an inspection is conducted by Transport Canada, it is done only as a courtesy. Before embarking on its last voyage, the EvanRichard had undergone a major refit to convert it from a lobster boat to a scallop dragger. Major modifications had been done to adapt it for the scallop fishery. However, like many other small fishing vessels, the refit was not reported to Transport Canada. This failure to report refits remains a systemic problem that threatens the safety of fishers. Consequently, it is up to the owners and masters to see that their vessels comply with the regulations, that the equipment on board is suitable, that the equipment is installed according to the manufacturer's instructions, and that it is operating properly. Failure of Power Assist According to the information received, the steering gear failed when the power assist was used to heave to. Inspection of the power assist circuits revealed that a fuse connected in series between the steering gear power unit and the drive interface had blown. To protect the power unit of the steering gear from current variations when the system is operating normally, the manufacturer provided 30A thermal protection inside the drive interface. According to the manufacturer, adding a 20Afuse (seeA in Figure2) does not increase system safety and can even prevent it from operating properly. It is important to note that the system was designed so that the steering gear would be used with either the telemotor or the power assist. Therefore, when the power assist failed, the telemotor could have been used to steer. In other words, the steering gear did not fail. Fishing Vessel Overloaded The EvanRichard was designed for lobster fishing. Approximately 100 lobster traps could be stowed on the after deck, representing a total weight of some 3000kg. At the time, fishers considered it hazardous to load this boat with that many lobster traps, and they waited for calm seas before going out. The EvanRichard had a cargo of some 6570kg, which was about twice the usual cargo weight at the time. With this cargo, the after deck was approximately 20cm below the waterline and the plugged scuppers were not watertight (seeAppendixA). The electric pump used to discharge water from the after deck had to operate throughout the whole voyage to keep the crew safe. The existing regulations for fishing vessels with a gross tonnage of under 15do not provide for stability testing before putting the vessel into service. As a result, there is no information regarding vessel stability and operation on board these small commercial vessels. As well, there are no regulations regarding freeboard marks and load lines; this safety measure does not exist on any fishing vessels. Therefore, every fishing master is responsible for evaluating the safety limit to which the vessel can be loaded. Although it was not mandatory, the master of the EvanRichard held a fishing master certificate. In addition, he had several years of experience at sea as the master of a fishing vessel with a gross tonnage of over165, on which a stability booklet is mandatory. However, although the master had this level of experience, the boat was overloaded. Deficiencies in Training and On-board Documentation Although Transport Canada issues fishing master certificates, the regulations do not apply to the majority of mariners whose principal occupation is commercial fishing. About 94percent of all registered fishing vessels have a gross tonnage of lessthan60. The only training that these mariners will have to take is marine emergency duties, and this requirement will not be in effect until 2007. To be able to assess the effect of cargo on the dynamic behaviour of a vessel, the crew must understand certain principles of stability and have some general knowledge of loading and vessel construction. Since1979, the topic general knowledge of the vessel has been included in the syllabus of knowledge required to earn a fishing master, first-class, second-class, or third-class certificate. In spite of this, there is a deficiency with regard to stability. To correct this deficiency, the CCG published a booklet entitled Introduction to Fishing Vessel Stability (TP8161). The booklet provides an introduction to the principles of stability and the factors that affect stability. In2002, Transport Canada added to the syllabus the requirement to understand the principles of stability in order to qualify for a fishing master, first-class, second-class, or third-class certificate. However, when the master of the EvanRichard was in training to qualify for a fishing master, third-class certificate, he was not required to learn about stability. In1989, the CCG published a booklet entitled Small Fishing Vessel Safety Manual (TP10038). Today, this booklet re-issued by Transport Canada is mainly intended for masters and operators of small fishing vessels of under 24m who do not hold a certificate of qualification or who have had only limited occupational training. There is no regulatory requirement for stability testing for fishing vessels with a gross tonnage of 15or less that are not sailing vessels.5 Yet, most appliances that we buy, irrespective of their size and intended purpose, are sold with a user manual. With no specific information on the stability of their vessel, the owners and masters of these small fishing vessels are limited in the decisions that they must make regarding loading parameters and limits. Lacking appropriate documentation and adequate training on stability, the owner/master of the EvanRichard exceeded the safe loading limits. As stated in the TSB investigation report (M01L0112) on the accident involving the AlexB.1, various actions have been undertaken by provincial governments and Transport Canada to raise safety awareness among fishers. However, without an obligation to have an operating manual and stability booklet on all fishing vessels, and to have owners take training suited to their occupation, fishers will continue to operate their vessels as they wish. Voyage Planning Fishers tend to overestimate the seaworthiness of their vessels and underestimate the forces of nature. Sound planning is essential for a successful voyage. Planning must make use of all resources available. Without the complete documentation, it is difficult to plan options in the event of an emergency, for example, to select an alternate anchorage or to consult a document to determine on what frequency weather reports are broadcast. As stated above, fishing master certificates do not apply to the majority of masters of small fishing vessels. In other words, masters are not required to take specific training. However, the Transport Canada publication Small Fishing Vessel Safety Manual (TP10038) contains a chapter devoted to weather information that explains the effects of weather on a small vessel. At approximately 0600 on 29September2003, a peak wind of 46knots from the south-southeast was recorded at the Pointe Heath observation station. The EvanRichard had anchored 5.5nautical miles from the observation station. This initial choice as an anchorage was not an unwise decision, since this location was satisfactory until the evening of 28September. However, in less than 12hours, the wind changed direction and doubled in velocity, and the seas rose to approximately 6m; the anchorage was no longer sheltered. If radio watch had been maintained on one of the frequencies that provided weather forecasts, the crew would have known that their anchorage was no longer adequate. Environment Canada weather reports are broadcast by the CCG MCTS all day on channels reserved for that purpose, namely VHF21B, 25Band83B on the Atlantic coast and the Great Lakes. Environment Canada also provides the service WeatherRadio Canada on VHF channelsWX1, WX2 andWX3. Weather reports are also broadcast on AM and FM radio. No weather information is broadcast on VHF channel9 in the area of Anticosti Island. Mariners are responsible for considering the weather when planning a voyage. In 1979, the CCG introduced an exam on meteorology to qualify for a fishing master, first-class or second-class certificate. It was not until2002 that Transport Canada added this subject to the syllabus for the fishing master, third-class certificate. Since the master of the EvanRichard had received his certificate in1995, he was not required to take this training. Choice of Rescue Equipment The EvanRichard was on a home-trade voyage, ClassIII. Although the boat sank just a few hundred metres from the coast, the two seamen have not been found. Furthermore, the EvanRichard came close to disappearing without a trace; the last Mayday was received with difficulty by the MCTS at Rivire-au-Renard. The current regulations that apply to fishing vessels like the EvanRichard require that every person on board must have a lifejacket. The regulations also require that decked fishing vessels with a gross tonnage of over 15be equipped with a lifeboat, boat, dory, skiff or seiner to accommodate all persons on board. Furthermore, if the fishing vessel exceeds 12.2m in length, a liferaft is also required. However, fishing vessels of 150 gross tons or more or 24.4m or more in length are required to be equipped with immersion suits when they are engaged in voyages other than home-trade voyages, ClassIV and minor waters voyages, ClassII. The EvanRichard was towing a lifeboat, but because it was incorrectly positioned and incorrectly attached, it could not be used by the crew. Since the seamen could not swim, an inflatable raft, an immersion suit or lifejackets strategically positioned near the accommodation would have enabled these men to make it to shore safely. The EvanRichard was not required to have an EPIRB on board. Under the existing regulations, only fishing vessels under 15gross tons of a length of 8m or more and which are engaged in home-trade voyages, ClassI orII or foreign voyages are required to have an EPIRB on board. An EPIRB that activates automatically could have transmitted a specific Mayday signal, which would have limited the search perimeter to the minimum. The EvanRichard was overloaded to the point where the scuppers were submerged, thereby facilitating downflooding. When the power assist failed, the master did not use the steering telemotor. The anchorage chosen provided little shelter from winds and waves from the southeast.Findings as to Causes and Contributing Factors The EvanRichard was overloaded to the point where the scuppers were submerged, thereby facilitating downflooding. When the power assist failed, the master did not use the steering telemotor. The anchorage chosen provided little shelter from winds and waves from the southeast. are not tested for stability and have no operating manual, are not required to be inspected by Transport Canada or to be inspected after a refit. are not tested for stability and have no operating manual, are not required to be inspected by Transport Canada or to be inspected after a refit. Like all fishing vessels in Canada, the EvanRichard had no freeboard marks or load lines to limit the loaded draught. Fishing vessels with a gross tonnage of less than 150or a length of 24.4m or less are not required to carry a liferaft or immersion suits. Under the existing regulations, only fishing vessels with a gross tonnage of less than 15and a length of 8m or more when engaged in home-trade voyages, ClassI orII or foreign voyages are required to have an emergency position indicating radio beacon (EPIRB) on board. Fishing masters who received their third-class certificates before2002 did not receive training on vessel stability and meteorology and are not required to have such training.Findings as to Risk are not tested for stability and have no operating manual, are not required to be inspected by Transport Canada or to be inspected after a refit. are not tested for stability and have no operating manual, are not required to be inspected by Transport Canada or to be inspected after a refit. Like all fishing vessels in Canada, the EvanRichard had no freeboard marks or load lines to limit the loaded draught. Fishing vessels with a gross tonnage of less than 150or a length of 24.4m or less are not required to carry a liferaft or immersion suits. Under the existing regulations, only fishing vessels with a gross tonnage of less than 15and a length of 8m or more when engaged in home-trade voyages, ClassI orII or foreign voyages are required to have an emergency position indicating radio beacon (EPIRB) on board. Fishing masters who received their third-class certificates before2002 did not receive training on vessel stability and meteorology and are not required to have such training. Transport Canada issues fishing master certificates, but 94percent of the masters of fishing vessels registered in Canada are not required to have a fishing master certificate.Other Finding Transport Canada issues fishing master certificates, but 94percent of the masters of fishing vessels registered in Canada are not required to have a fishing master certificate. Safety Action Transport Canada The Small Fishing Vessel Inspection Regulations are part of the first phase of the regulatory reform undertaken by Transport Canada to implement the Canada Shipping Act,2001. Despite the progress made in implementing the work of the various teams, implementation of this new Act and the regulations made thereunder is not scheduled until2006. Based on the 1993proposal, which has not been enacted, Transport Canada started a major review of the regulations applicable to all fishing vessels. The first phase concerns fishing vessels with a gross tonnage of less than150; the Small Fishing Vessel Inspection Regulations covers this group of vessels. Further to biennial meetings of the Canadian Marine Advisory Council (CMAC), sponsored by the CMAC's Standing Committee on Fishing Vessel Safety and to public consultations including fishers held in several communities, Transport Canada filed a working document in February2004 to be used as a reference document in the next round of public consultations and, consequently, in drafting the new Small Fishing Vessel Inspection Regulations. Amendments are anticipated in the following areas: voyage classifications; lifesaving equipment; inspections; stability and seaworthiness; construction (a technical standard), plans and information; operation and maintenance; navigation safety and radiocommunication equipment; and certification and training. Transport Canada intends to develop a new regulatory regime including regulations and standards that will ensure an acceptable level of risk and that can be suitably administered within the national and international regulatory framework.